Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, behavioral disturbances, and frequent exit-seeking behaviors successfully eloped from the facility. The resident had a documented risk of elopement, as evidenced by a recent assessment and multiple progress notes indicating repeated attempts to leave the facility, including a prior successful exit. The care plan included the use of a Wanderguard device, but the resident refused to wear it on her wrist, so it was attached to her walker, which she rarely used. On the day of the incident, the resident exited through a delayed egress door that alarmed, but staff did not immediately respond to the alarm or recognize the resident's absence until several minutes later. Staff interviews and record reviews revealed that the alarm on the exit door was heard by a CNA, who checked the area briefly but did not conduct a thorough search before resetting the alarm, assuming the resident was elsewhere in the building. Other staff members began searching rooms only after realizing the resident was missing, and the charge nurse was unfamiliar with the elopement protocol, leading to delays in initiating a missing person alert. The resident was ultimately found outside the facility by emergency personnel after being unsupervised for approximately 19 minutes near a busy street and ambulance garage. Further review showed that staff had not received adequate education or debriefing following the elopement, and there was a lack of consistent implementation of interventions for the resident's exit-seeking behaviors. The resident's room was located near an exit that was not easily visible from the nurses' station, and staff responses to alarms were inconsistent, with some assuming others would respond. The facility's policy required specific precautions for residents at risk of elopement, but these were not effectively implemented in this case.
Removal Plan
- All staff will be educated that they acknowledge and understand that in the event they hear an exit door alarming, they observe the alarm on the facility monitors or a page is obtained stating that an exit door has been opened or is alarming they will respond to investigate.
- If staff are caring for a resident when this alert is obtained, they will ensure their resident is safe and then respond.
- Staff that have not signed stating understanding will not be permitted to work until education has been obtained.
- Any staff who are found not to be compliant will be reeducated.
- Door alarms were set off and notifications were verified to be sent to staff pagers and facility monitors.
- Resident #1 will be moved to the locked unit in LTC once appropriate notifications have been made due to her noncompliance to wear a wanderguard and her risk of elopement.
- Until this move occurs Resident #1 will be placed on 1:1 monitoring when out of her room.
- All residents who score a 1.0 or higher on the elopement assessment have been reassessed to ensure proper interventions are in place.
- Any resident in the facility that is deemed to be an elopement risk a wanderguard will be placed and care planned for that resident.
- Any resident that is refusing to wear a wanderguard will be moved to the locked unit in long term care for increased supervision and safety.
- If a bed is not available in the locked unit, the resident will be placed on 1:1 supervision until an appropriate room is available.